HomeMy WebLinkAboutSeptic Pumping Slip - 54 CEDAR LANE 8/15/2017 C bmrri6lliW let
ealth of Massachusetts
City/Tow' n of North Andover .
S
YS tem Pumping Record
I
Form 4 100 J\AD�'?
0\-
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
-the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351.
A. Facility Information
Important:When
filling out forms . 1. System Location:
on the computer,
use only the tab
key to move your AcIts
cursor-do not t
use the return
key. Cityrrown State Zip Code
2. S" stem Owner:
Address(if different from location) ...........
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped:
Date IGIbIlons
3. Component: ❑ Cesspool(s) Septic Tank n Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ❑ Yes Ej No
5. ObservedKondition rof t mponen pumped:
6. System P ed B
Name Vehicle License Number
Stewarts Septi 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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